Borchers Andrea Ann (ed.) Handbook of Signs & Symptoms 2015

Mesenteric artery occlusion. After a brief period of hyperactivity, bowel sounds become hypoactive and then quickly disappear, signifying a life-threatening crisis. Associated signs and symptoms include fever; a history of colicky abdominal pain leading to sudden and severe midepigastric or periumbilical pain, followed by abdominal distention and possible bruits; vomiting; constipation; and signs of shock. Abdominal rigidity may appear late.

Paralytic (adynamic) ileus. Bowel sounds are hypoactive and may become absent. Associated signs and symptoms include abdominal distention, generalized discomfort, and constipation or passage of small, liquid stools and flatus. If the disorder follows acute abdominal infection, fever and abdominal pain may occur.

Other Causes

Drugs. Certain classes of drugs reduce intestinal motility and thus produce hypoactive bowel sounds. These include opiates, such as codeine; anticholinergics, such as propantheline bromide; phenothiazines, such as chlorpromazine; and Vinca alkaloids, such as vincristine. General or spinal anesthetics produce transient hypoactive sounds.

Radiation therapy. Hypoactive bowel sounds and abdominal tenderness may occur after irradiation of the abdomen.

Surgery. Hypoactive bowel sounds may occur after manipulation of the bowel. Motility and bowel sounds in the small intestine usually resume within 24 hours; colonic bowel sounds, in 3 to 5 days.

Special Considerations

Frequently evaluate the patient with hypoactive bowel sounds for indications of shock (thirst; anxiety; restlessness; tachycardia; cool, clammy skin; weak, thready pulse), which can develop if peristalsis continues to diminish and fluid is lost from the circulation.

Be alert for the sudden absence of bowel sounds, especially in the postoperative patient or a patient with hypokalemia because there’s an increased risk of paralytic ileus. Monitor the patient’s vital signs and auscultate for bowel sounds every 2 to 4 hours.

Severe pain, abdominal rigidity, guarding, and fever, accompanied by hypoactive bowel sounds, may indicate paralytic ileus from peritonitis. If these signs and symptoms occur, prepare for emergency interventions. (See “Bowel Sounds, Absent,” pages 106 to 108.)

The patient with hypoactive bowel sounds may require GI suction and decompression, using a nasogastric or intestinal tube. If so, restrict the patient’s oral intake. Then, elevate the head of the bed at least 30 degrees, and turn the patient to facilitate passage of the tube through the GI tract.

Remember not to tape an intestinal tube to the patient’s face. Ensure tube patency by watching for drainage and properly functioning suction devices. Irrigate the tube, and closely monitor drainage.

Continue to administer I.V. fluids and electrolytes, and send a serum specimen to the laboratory for electrolyte analysis at least once per day. Recognize that the patient may need X-ray studies, endoscopic procedures, and further blood work to determine the cause of hypoactive bowel sounds.

Provide comfort measures as needed. Semi-Fowler’s position offers the best relief for the patient with paralytic ileus. Sometimes, getting the patient to ambulate can reactivate the sluggish bowel. However, if the patient can’t tolerate ambulation, range-of-motion exercises or turning from side to side may stimulate peristalsis. Also, turning the patient from side to side helps move gas through the

intestines.

Patient Counseling

Tell the caregiver that ambulation or frequent turning are important; tell him to maintain food and fluid restrictions. Teach the patient or caregiver about the need for diagnostic tests and procedures.

Pediatric Pointers

Hypoactive bowel sounds in a child may simply be due to bowel distention from excessive swallowing of air while the child was eating or crying. However, make sure to observe the child for further signs of illness. As with an adult, sluggish bowel sounds in a child may signal the onset of paralytic ileus or peritonitis.

REFERENCES

Lau, J. Y. , Sung, J. , Hill, C. , Henderson, C. , Howden, C. W. , & Metz, D. C. (2011) . Systematic review of the epidemiology of complicated peptic ulcer disease: Incidence, recurrence, risk factors and mortality. Digestion, 84: 102–113.

Malfertheiner, P., Chan, F. L., & McColl, K. L. (2009). Peptic ulcer disease. Lancet, 374, 1449–1461.

Bradycardia

Bradycardia refers to a heart rate of less than 60 beats/minute. It occurs normally in young adults, trained athletes, and elderly people as well as during sleep. It’s also a normal response to vagal stimulation caused by coughing, vomiting, or straining during defecation. When bradycardia results from these causes, the heart rate rarely drops below 40 beats/minute. However, when it results from pathologic causes (such as cardiovascular disorders), the heart rate may be slower.

By itself, bradycardia is a nonspecific sign. However, in conjunction with such symptoms as chest pain, dizziness, syncope, and shortness of breath, it can signal a life-threatening disorder.

History and Physical Examination

After detecting bradycardia, check for related signs of life-threatening disorders. (See Managing Severe Bradycardia , page 114.) If the patient’s bradycardia isn’t accompanied by untoward signs, ask the patient if he or a family member has a history of a slow pulse rate because this may be inherited. Also, find out if he has an underlying metabolic disorder, such as hypothyroidism, which can precipitate bradycardia. Ask which medications he’s taking and if he’s complying with the prescribed schedule and dosage. Monitor his vital signs, temperature, pulse, respirations, blood pressure, and oxygen saturation.

Medical Causes

Cardiac arrhythmia. Depending on the type of arrhythmia and the patient’s tolerance of it, bradycardia may be transient or sustained, benign or life threatening. Related findings include hypotension, palpitations, dizziness, weakness, syncope, and fatigue.

Cardiomyopathy. Cardiomyopathy is a potentially life-threatening disorder that may cause transient or sustained bradycardia. Other findings include dizziness, syncope, edema, fatigue, jugular vein distention, orthopnea, dyspnea, and peripheral cyanosis.

EMERGENCY INTERVENTIONS Managing Severe

Bradycardia

Bradycardia can signal a life-threatening disorder when accompanied by pain, shortness of breath, dizziness, syncope, or other symptoms, prolonged exposure to cold, or head or neck trauma. In such a patient, quickly take his vital signs. Connect the patient to a cardiac monitor, and insert an I.V. line. Depending on the cause of bradycardia, you’ll need to administer fluids, atropine, or thyroid medication. If indicated, insert an indwelling urinary catheter. Intubation, mechanical ventilation, or placement of a pacemaker may be necessary if the patient’s respiratory rate falls.

If appropriate, perform a focused evaluation to help locate the cause of bradycardia. For example, ask about pain. Viselike pressure or crushing or burning chest pain that radiates to the arms, back, or jaw may indicate an acute myocardial infarction (MI); a severe headache may indicate increased intracranial pressure. Also, ask about nausea, vomiting, or shortness of breath

— signs and symptoms associated with an acute MI and cardiomyopathy. Observe the patient for peripheral cyanosis, edema, or jugular vein distention, which may indicate cardiomyopathy. Look for a thyroidectomy scar because severe bradycardia may result from hypothyroidism caused by failure to take thyroid hormone replacements.

If the cause of bradycardia is evident, provide supportive care. For example, keep the hypothermic patient warm by applying blankets, and monitor his core temperature until it reaches 99°F (37.2°C); stabilize the head and neck of a trauma patient until cervical spinal injury is ruled out.

Hypothermia. Bradycardia usually appears when the core temperature drops below 89.6°F (32°C). It’s accompanied by shivering, peripheral cyanosis, muscle rigidity, bradypnea, and confusion leading to stupor.

Hypothyroidism. Hypothyroidism causes severe bradycardia in addition to fatigue, constipation, unexplained weight gain, and sensitivity to cold. Related signs include cool, dry, thick skin; sparse, dry hair; facial swelling; periorbital edema; thick, brittle nails; and confusion leading to stupor.

Myocardial infarction (MI). Sinus bradycardia is the most common arrhythmia associated with an acute MI. Accompanying signs and symptoms of an MI include an aching, burning, or viselike pressure in the chest that may radiate to the jaw, shoulder, arm, back, or epigastric area; nausea and vomiting; cool, clammy, and pale or cyanotic skin; anxiety; and dyspnea. Blood pressure may be elevated or depressed. Auscultation may reveal abnormal heart sounds.

Other Causes

Diagnostic tests. Cardiac catheterization and electrophysiologic studies can induce temporary bradycardia.

Drugs. Beta-adrenergic blockers and some calcium channel blockers, cardiac glycosides,

topical miotics (such as pilocarpine), protamine, quinidine and other antiarrhythmics, and sympatholytics may cause transient bradycardia. Failure to take thyroid replacements may cause bradycardia.

Invasive treatments. Suctioning can induce hypoxia and vagal stimulation, causing bradycardia. Cardiac surgery can cause edema or damage to conduction tissues, causing bradycardia.

Special Considerations

Continue to monitor the patient’s vital signs frequently. Be especially alert for changes in cardiac rhythm, respiratory rate, and the level of consciousness.

Prepare the patient for laboratory tests, which can include complete blood count; cardiac enzyme, serum electrolyte, blood glucose, blood urea nitrogen, arterial blood gas, and blood drug levels; thyroid function tests; and a 12-lead electrocardiogram. If appropriate, prepare the patient for 24-hour Holter monitoring.

Patient Counseling

Inform the patient about signs and symptoms he should report. Give instructions for pulse measurement, and explain the parameters for calling the physician and seeking emergency care. If a patient is getting a pacemaker, explain its use.

Pediatric Pointers

Heart rates are normally higher in children than in adults. Fetal bradycardia — a heart rate of less than 120 beats/minute — may occur during prolonged labor or complications of delivery, such as compression of the umbilical cord, partial abruptio placentae, and placenta previa. Intermittent bradycardia, sometimes accompanied by apnea, commonly occurs in premature infants. Bradycardia rarely occurs in full-term infants or children. However, it can result from congenital heart defects, acute glomerulonephritis, and transient or complete heart block associated with cardiac catheterization or cardiac surgery.

Geriatric Pointers

Sinus node dysfunction is the most common bradyarrhythmia encountered among the elderly. Patients with this disorder may have as their chief complaint fatigue, exercise intolerance, dizziness, or syncope. If patients are asymptomatic, no intervention is necessary. Symptomatic patients, however, require careful scrutiny of their drug therapy. Beta-adrenergic blockers, verapamil, diazepam, sympatholytics, antihypertensives, and some antiarrhythmics have been implicated; symptoms may clear when these drugs are discontinued. Pacing is usually indicated in patients with symptomatic bradycardia lacking a correctable cause.

REFERENCES

Guly, H. R., Bouamra, O. , Little, R. , Dark, P. , Coats, T. , Driscoll, P., & Lecky, F. E. (2010) . Testing the validity of the ATLS classification of hypovolemic shock. Resuscitation, 81, 1142–1147.

Mutschler, M., Nienaber, U., Brockamp, T., Wafaisade, A., Wyen, H., Peiniger, S., … Maegele, M. (2012). A critical reappraisal of the ATLS classification of hypovolaemic shock: Does it really reflect clinical reality? Resuscitation, 84: 309–313. doi:10.1016/ j.resuscitation.2012.07.012.

Bradypnea

Commonly preceding life-threatening apnea or respiratory arrest, bradypnea is a pattern of regular respirations with a rate of fewer than 10 breaths/minute. This sign results from neurologic and metabolic disorders and drug overdose, which depress the brain’s respiratory control centers. (See

Understanding How the Nervous System Controls Breathing, page 116.)

EMERGENCY INTERVENTIONS

Depending on the degree of central nervous system (CNS) depression, the patient with severe bradypnea may require constant stimulation to breathe. If the patient seems excessively sleepy, try to arouse him by shaking and instructing him to breathe. Quickly take the patient’s vital signs. Assess his neurologic status by checking pupil size and reactions and by evaluating his level of consciousness (LOC) and his ability to move his extremities.

Place the patient on an apnea monitor and pulse oximeter, keep emergency airway equipment available, and be prepared to assist with intubation and mechanical ventilation if spontaneous respirations cease. To prevent aspiration, position the patient on his side or keep his head elevated 30 degrees higher than the rest of his body, and clear his airway with suction or finger sweeps, if necessary. Administer opioid antagonists, as ordered.

History and Physical Examination

Obtain a brief history from the patient, if possible. Alternatively, obtain this information from whoever accompanied him to your facility. Ask if he’s experiencing a drug overdose and, if so, try to determine what drugs he took, how much, when, and by what route. Check his arms for needle marks, indicating possible drug abuse. You may need to administer I.V. naloxone, an opioid antagonist.

Understanding How the Nervous System Controls Breathing

Stimulation from external sources and from higher brain centers acts on respiratory centers in the pons and medulla. These centers, in turn, send impulses to the various parts of the respiratory system to alter respiration patterns.

If you rule out a drug overdose, ask about chronic illnesses, such as diabetes and renal failure. Check for a medical identification bracelet or an I.D. card that identifies an underlying condition. Also, ask whether the patient has a history of head trauma, brain tumor, neurologic infection, or stroke.

Medical Causes

Diabetic ketoacidosis. Bradypnea occurs late in patients with severe, uncontrolled diabetes. Patients with severe ketoacidosis may experience Kussmaul’s respirations. Associated signs and symptoms include a decreased LOC, fatigue, weakness, a fruity breath odor, and oliguria.

Hepatic failure. Occurring with end-stage hepatic failure, bradypnea may be accompanied by coma, hyperactive reflexes, asterixis, a positive Babinski’s sign, fetor hepaticus, and other signs. Increased intracranial pressure (ICP). A late sign of increased ICP, a life-threatening condition, bradypnea is preceded by a decreased LOC, deteriorating motor function, and fixed, dilated pupils. The triad of bradypnea, bradycardia, and hypertension is a classic sign of late medullary strangulation.

Renal failure. Occurring with end-stage renal failure, bradypnea may be accompanied by convulsions, a decreased LOC, GI bleeding, hypotension or hypertension, uremic frost, and

Geriatric Pointers

When drugs are prescribed for older patients, keep in mind that the elderly have a higher risk of developing bradypnea secondary to drug toxicity. That’s because many of these patients take several drugs that can potentiate this effect and typically have other conditions that predispose them to it. Warn older patients about this potentially life-threatening complication.

REFERENCES

Chung, F. , Abrishami, A., & Khajehdehi, A. (2010) . A systematic review of screening questionnaires for obstructive sleep apnea.

Canadian Journal of Anaesthesia, 57(5), 423–438.

Dahan, A. , Aarts, L., & Smith, T. W. (2010) . Incidence, reversal, and prevention of opioid-induced respiratory depression. Anesthesiology, 112(1), 226–238.

Breast Dimpling

(See also Breast nodule, Breast Pain, Breast Ulcer)

Breast dimpling — the puckering or retraction of skin on the breast — results from abnormal attachment of the skin to underlying tissue. It suggests an inflammatory or malignant mass beneath the skin surface and usually represents a late sign of breast cancer; benign lesions usually don’t produce this effect. Dimpling usually affects women older than age 40, but also occasionally affects men.

Because breast dimpling occurs over a mass or induration, the patient usually discovers other signs before becoming aware of the dimpling. However, a thorough breast examination may reveal

dimpling and alert the patient and nurse to a problem.

History and Physical Examination

Obtain a medical, reproductive, and family history, noting factors that place the patient at a high risk for breast cancer. Ask about pregnancy history because women who haven’t had a full-term pregnancy before age 30 are at higher risk for developing breast cancer. Has her mother or a sister had breast cancer? Has she herself had a previous malignancy, especially cancer in the other breast? Ask about the patient’s dietary habits because a high-fat diet predisposes women to breast cancer.

Ask the patient if she has noticed changes in the shape of her breast. Is any area painful or tender, and is the pain cyclic? If she’s breast-feeding, has she recently experienced high fever, chills, malaise, muscle aches, fatigue, or other flulike signs or symptoms? Can she remember sustaining trauma to the breast?

Carefully inspect the dimpled area. Is it swollen, red, or warm to the touch? Do you see bruises or contusions? Ask the patient to tense her pectoral muscles by pressing her hips with both hands or by raising her hands over her head. Does the puckering increase? Gently pull the skin upward toward the clavicle. Is the dimpling exaggerated?

Observe the breast for nipple retraction. Do both nipples point in the same direction? Are the nipples flattened or inverted? Does the patient report nipple discharge? If so, ask her to describe the color and character of the discharge. Observe the contour of both breasts. Are they symmetrical?

Examine both breasts with the patient lying down, sitting, and then leaning forward. Does the skin move freely over both breasts? If you can palpate a lump, describe its size, location, consistency, mobility, and delineation. What relation does the lump have to the breast dimpling? Gently mold the breast skin around the lump. Is the dimpling exaggerated? Also, examine breast and axillary lymph nodes, noting any enlargement.

Medical Causes

Breast abscess. Breast dimpling sometimes accompanies a chronic breast abscess. Associated findings include a firm, irregular, nontender lump and signs of nipple retraction, such as deviation, inversion, or flattening. Axillary lymph nodes may be enlarged.

Breast cancer. Breast dimpling is an important, but somewhat late sign of breast cancer. A neoplasm that causes dimpling is usually close to the skin and at least 1 cm in diameter. It feels irregularly shaped and fixed to underlying tissue, and it’s usually painless. Other signs of breast cancer include peau d’orange, changes in breast symmetry or size, nipple retraction, and a unilateral, spontaneous, nonmilky nipple discharge that’s serous or bloody. (A bloody nipple discharge in the presence of a lump is a classic sign of breast cancer.) Axillary lymph nodes may be enlarged. Pain may be present but isn’t a reliable symptom of breast cancer. A breast ulcer may appear as a late sign.

Fat necrosis. Breast dimpling from fat necrosis follows inflammation and trauma to the fatty tissue of the breast (although the patient usually can’t remember such trauma). Tenderness, erythema, bruising, and contusions may occur. Other findings include a hard, indurated, poorly delineated lump, which is fibrotic and fixed to underlying tissue or overlying skin as well as signs of nipple retraction. Fat necrosis is difficult to differentiate from breast cancer.

Mastitis. Breast dimpling may signal bacterial mastitis, which usually results from duct obstruction and milk stasis during lactation. Heat, erythema, swelling, induration, pain, and

tenderness usually accompany mastitis. Dimpling is more likely to occur with diffuse induration than with a single hard mass. The skin on the breast may feel fixed to underlying tissue. Other possible findings include nipple retraction, nipple cracks, a purulent discharge, and enlarged axillary lymph nodes. Flulike signs and symptoms (such as fever, malaise, fatigue, and aching) commonly occur.

Special Considerations

Remember that any breast problem can arouse fears of altered body image, mutilation, loss of sexuality, and death. Allow the patient to express her feelings.

Patient Counseling

Explain what to expect during diagnostic testing and the importance of clinical breast examination and mammography, following the American Cancer Society guidelines. Teach the patient how to perform breast self-examination and about the cause of breast dimpling. Also, teach her about the treatment plan after a diagnosis is established. If the patient breast-feeds and has mastitis, advise her to pump her breasts to prevent milk stasis, to discard the milk, and to substitute formula until the infection resolves.

Pediatric Pointers

Because breast cancer, the most likely cause of dimpling, is extremely rare in children, consider trauma as a likely cause. As in adults, breast dimpling may occur in adolescents from fatty tissue necrosis due to trauma.

REFERENCES

Jemal, A. , Bray, F. , Center, M. M., Ferlay, J. , Ward, E., & Forman, D. (2011) . Global cancer statistics. CA: Cancer Journal Clinicians, 61(2), 69–90.

Moyer, V. A. (2013). Risk assessment, genetic counseling, and genetic testing for BRCA-related cancer in women: U.S. preventive services task force recommendation statement. Annals of Internal Medicine, 160: 271–281.

Breast Nodule

(See Also Breast Dimpling, Breast Pain, Breast Ulcer) [Breast lump]

A commonly reported gynecologic sign, a breast nodule has two chief causes: benign breast disease and cancer. Benign breast disease, the leading cause of nodules, can stem from cyst formation in obstructed and dilated lactiferous ducts, hypertrophy or tumor formation in the ductal system, inflammation, or infection.

Although fewer than 20% of breast nodules are malignant, the signs and symptoms of breast cancer aren’t easily distinguished from those of benign breast disease. Breast cancer is a leading cause of death among women, but can occur occasionally in men, with signs and symptoms mimicking those found in women. Thus, breast nodules in both sexes should always be evaluated.